Aortic stenosis: medical and surgical management.

Correspondence to: Professor Helmut Baumgartner, MD, Department of Cardiology, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18–20, A – 1090 Wien, Austria; helmut.baumgartner@ meduniwien.ac.at _________________________ A ortic stenosis (AS) has become the most frequent valvar heart disease and the most frequent cardiovascular disease after hypertension and coronary artery disease in Europe and North America. It primarily presents as calcific AS in adults of advanced age. The prevalence in the population older than 65 years has been reported between 2–7% and aortic sclerosis, the precursor of AS, has been found in 25%. Considering this high prevalence and the poor outcome of AS without cardiac surgery, this disease has definitely become a major health problem. Besides calcific AS, the second most frequent aetiology which dominates in the younger age group is congenital AS, whereas rheumatic AS has become very rare in developed countries. Among patients with calcific AS, bicuspid valves are very common in those presenting in their 70s and 80s, whereas tricuspid valves become more common in octogenarians. Proper physical examination remains essential in AS. It is the characteristic systolic murmur that draws attention and guides further diagnostic workup in the right direction. Doppler echocardiography is the ideal tool to confirm diagnosis and quantify AS by calculating pressure gradients and valve area, although the technique remains investigator dependent requiring special skill and experience. Heart catheterisation is mostly restricted to preoperative evaluation of coronary arteries rather than for evaluation of the valve lesion itself. During a long latent period with increasing outflow tract obstruction, which results in increasing left ventricular pressure load, patients remain asymptomatic and acute complications are rare. However, as soon as symptoms such as exertional dyspnoea, angina, or dizziness and syncope occur, outcome becomes dismal. Average survival after the onset of symptoms has been reported to be less than 2–3 years. In this situation, valve replacement not only results in dramatic symptomatic improvement but also in good long term survival. This holds true even for patients with already reduced left ventricular function, as long as functional impairment is indeed caused by AS. Thus, there is general agreement that urgent surgery must be strongly recommended in symptomatic patients. 4 This article primarily addresses two controversial issues on which current research efforts focus in particular: (1) the pathogenesis of calcific AS and possible ways to halt progression to severe symptomatic AS; and (2) the question of whether and when to operate on asymptomatic, haemodynamically severe AS.